Falls in the elderly

Question 1

What is the definition of a fall?

Answer 1

An event which causes a person to, unintentionally, rest on the ground or lower level

Result of interplay of multiple risk factors, becoming much more likely as people get older

Not a result of a major intrinsic event such as a stroke

Question 2

Why are falls important?

Answer 2

• Falling is a cause of distress, pain, injury, loss of confidence, loss of independence and mortality.
• 65 and over have the highest risk of falling
• 1/3 of people 65 and over and 1/2 of people 80 and over fall at least once a year

Question 3

How much does falls cost the NHS?

Answer 3

£435 million

255,000 emergency hospital admissions related to falls among patients aged 65 and over

Falls in hospitals are the most common patient safety incident.

240,000 reported in acute hospitals and mental health trusts in England and Wales

Question 4

What are the potential consequence of falls in older people?

Answer 4

Biological:

Death, fracture, bruising, pain, soft tissue injury, long lies on floor

Psychological:

Distress, anxiety, depression, carer anxiety and abuse

Social:

Loss of independence and hobbies, dependence on others, family tension and stress and institutionalisation/moving to safer surroundings

Question 5

If a elderly patient falls and is unable to get back up, what are the potential consequences of lying on the floor for too long?

Answer 5

Lying on the floor for more than an hour can result in:

Pressure sores

Rhabdomyolysis

Hypothermia

Pneumonia

Question 6

At what time of day are falls most likely to occur?

Answer 6

Mid afternoon

Question 7

What are the most likely ways that fall may happen?

Answer 7

41% shifting of body weight

21% trip or stumble

11% hit or bump

27% other causes

Question 8

Name 5 common causes of falls - intrinsic factors

Answer 8

Syncope

Dizziness or vertigo

Seizures

Stroke

Visual impairment

Question 9

Define syncope

Answer 9

Sudden, transient loss of consciousness due to reduced cerebral perfusion

Patient will become:

unresponsive

loss of postural control

Then will have a spontaneous recovery

Question 10

Name 4 common causes of syncope

Answer 10

Orthostatic hypotension

Pain

Carotid sinus syndrome

Cardiac arrhythmia or ischaemia

Pulmonary embolism

Question 11

When could a TIA/stroke cause syncope?

Answer 11

TIA/stroke very rarely cause syncope - they cause focal deficit

Only cause syncope in the case of brainstem ischaemia

Question 12

Name 5 common causes of falls - Extrinsic factors

Answer 12

Poor lighting - especially on steps/stairs

Clutter around the home

Inappropriate footwear - open-backed slippers, high heels etc.

Incorrect use of walking aids

Pets or children

Question 13

What is the acronym for common causes of falls?

Answer 13

DAME

D = Drugs

Poly-pharmacy, alcohol

A= = Age related changes

Gait, balance, sarcopenia, sensory impairment etc.

M= Medical

Syncope, Parkinsons, stroke etc.

E= Environmental

Obstacles, trailing wires, lighting

Question 14

Give 2 examples of how a fall can be multi-factorial

Answer 14

Poor lighting + poor vision => fall

Postural instability + orthostatic hypotension => fall

Question 15

How would you take a history for assessment of a fall?

Answer 15

SPLATTD

S= symptoms

P= previous falls

L= location

A= activity

T= time

T= trauma

D= drug history

Question 16

How would you examine a patient after they has taken a fall?

Answer 16

General appearance

Gait and balance

Pulse rate &rhythm

Postural BP

Listen for murmurs – esp. aortic stenosis

Neurological examination

Look for signs of Parkinson’s disease

Check vision & hearing

Examine neck & head movements

Consider screening for cognitive impairment

Question 17

What is Orthostatic “postural hypotension”

Answer 17

>20 mmHg fall in systolic BP and/or >10 mmHg fall in diastolic BP

within 3 minutes of standing with symptoms

Causes:

Drugs, chronic hypertension, volume depletion, autonomic failure (Parkinson’s, diabetes), prolonged bed rest, adrenal insufficiency

Treat the cause

Consider fludrocortisone or desmopressin.

Question 18

What is Post-prandial hypotension?

Answer 18

A fall of 20 mmHg in systolic blood pressure after the ingestion of a meal

Can have effect for up to 90 minutes

Alter timing of anti-hypertensives

Lie down / sit down after meals

Caffeine, fludrocortisone, NSAIDs

Question 19

How does visual impairment increase the risk of falling?

Answer 19

Common with increased age - multifactorial

Bifocals increase the risk of falling

Glaucoma

Macular degeneration

Retinopathy

Cataracts

Question 20

What investigations would you order after a fall?

Answer 20

Bloods: FBC U&E

Thyroid

Glucose

B12 and Folate

Calcium and phosphate

Others: BP ECG ECHO CT head EEG

Question 21

What is included in a multi-factorial risk assessment?

Answer 21

Identification of falls history

Assessment of:

Gait, balance, mobility and muscle weakness, osteoporosis risk, visual impairment and cognitive impairment

Neurological examination

Urinary incontinence

Home hazards

CV exam

Medication review

Question 22

Give examples of a multi-factorial intervention

Answer 22

Physiotherapist = Strength and balance training

Occupational therapist = Home hazard assessment and intervention

Optician = Vision assessment and referral

GP = Medication review, modification/withdrawal

GP = Management of causes and recognised risk factors